III. Preparations: Estrogen with Progesterone Combination

  1. Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
  2. Two pill regimen
    1. Estrogen taken daily (see options below)
    2. Progestin taken daily (see options below)
  3. Combination Pill
    1. Activella (Estradiol + Norethindrone) 0.5/0.1 or 1.0/0.5 daily
    2. Angeliq (Estradiol + Drospirenone) 0.5/0.25 or 1.0/0.5 daily
    3. Duavee (Conj. equine Estrogen + Bazedoxifene) 0.45/20 mg daily
    4. FemHRT (Ethinyl Estradiol + Norethindrone) 2.5 mcg/0.5 daily
    5. Prempro (Conjugated Estrogen + Medroxyprogesterone) 0.625/2.5 (or 0.3/1.5, 0.45/1.5, 0.625/5.0) daily
  4. Patch
    1. Climara Pro (Estradiol + Levonorgestrel) 0.45/0.015 applied once weekly
    2. Combipatch (Estradiol + Norethindrone) 0.05/0.14 or 0.05/0.25 applied twice weekly

IV. Preparations: Estrogen with Selective Estrogen Receptor Modulator (SERM)

  1. Background
    1. First agent in this combination class released in 2014 as alternative to combination Estrogen with Progesterone
    2. Unclear role outside of cases of Estrogen Replacement with intact Uterus, in which Progesterone is contraindicated
    3. SERMs add potential for increased adverse effects with no added benefit when used in combination with Estrogen
      1. No additional bone protection in Osteoporosis
  2. Agents
    1. Duavee (Conjugated Estrogen 0.45 mg with bazedoxifene 20 mg)
  3. References
    1. (2014) Presc Lett 21(3)

V. Preparations: Estrogens Options

  1. Estrogen must be taken with Progesterone if Uterus is intact (Endometrial Hyperplasia risk)
  2. Conjugated Estrogen (Premarin, Enjuvia) 0.625 mg orally daily (or 0.3, 0.45, 0.9, 1.25 mg)
  3. Estropipate (Ogen) 0.625 mg orally daily
  4. Esterified Estrogen (Estratab, Menest) 0.625 mg orally daily (or 0.3, 1.25, 2.5 mg)
  5. Estradiol (Estrace) 0.5 mg orally daily (or 1.0 or 2.0 mg)
  6. Estradiol transdermal patch (Estraderm, Alora, Climara, Minivelle) 0.05 mg patch/wk (or 0.025, 0.075 or 0.1)
  7. Estradiol transdermal gel (Divigel, Elestrin, Estrogel) 0.25, 0.5, 0.75 or 1.0 daily (depending on manufacturer)
  8. Evamist transdermal spray (1.53 per spray) start with 1 spray daily and advance to max of 3 sprays daily based on response

VI. Preparations: Progestin Options (choose one to accompany an Estrogen if intact Uterus)

  1. Provera 2.5 mg daily
  2. Norethindrone 0.35 mg daily
  3. Micronized Progesterone 0.1 mg daily

VII. Advantages: Compared with Sequential Estrogen Replacement

  1. Decreased uterine bleeding

VIII. Adverse effects

  1. Decreased Libido: Consider Estratest instead of Premarin
    1. Estrogen 1.25
    2. Methyltestosterone 2.5
  2. Recurrent Vaginal Bleeding
    1. Rule-out Endometrial Cancer with Endometrial Biopsy
    2. Change Estrogen Replacement regimen
      1. Estradiol 1 mg qd and
      2. Norethindrone Acetate (NETA) 0.1 to 0.5 mg qd
        1. NETA 0.1 mg: No bleeding in 79% at 1 year
        2. NETA 0.25 mg: No bleeding in 84% at 1 year
        3. NETA 0.5 mg: No bleeding in 90% at 1 year
    3. References
      1. Archer (1999) Obstet Gynecol 94:323-9 [PubMed]

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